Charlie A Sewalt1,2, Benjamin Y Gravesteijn3, Daan Nieboer3, Ewout W Steyerberg3,4, Dennis Den Hartog5, David Van Klaveren3. 1. Department of Public Health, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands. c.sewalt@erasmusmc.nl. 2. Trauma Research Unit, Department of Surgery, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands. c.sewalt@erasmusmc.nl. 3. Department of Public Health, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands. 4. Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands. 5. Trauma Research Unit, Department of Surgery, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands.
Abstract
BACKGROUND: Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers. METHODS: We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit. RESULTS: We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92-0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%). CONCLUSIONS: Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles.
BACKGROUND: Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers. METHODS: We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit. RESULTS: We included 388,845 traumapatients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92-0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%). CONCLUSIONS: Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles.
Authors: Ellen J MacKenzie; Frederick P Rivara; Gregory J Jurkovich; Avery B Nathens; Katherine P Frey; Brian L Egleston; David S Salkever; Daniel O Scharfstein Journal: N Engl J Med Date: 2006-01-26 Impact factor: 91.245
Authors: Howard R Champion; Louis V Lombardo; Charles E Wade; Ellen J Kalin; Mary M Lawnick; John B Holcomb Journal: J Trauma Acute Care Surg Date: 2016-09 Impact factor: 3.313
Authors: C A Sewalt; E Venema; E J A Wiegers; F E Lecky; S C E Schuit; D den Hartog; E W Steyerberg; H F Lingsma Journal: Br J Surg Date: 2019-09-10 Impact factor: 6.939